Basic Information
| Provider Information | |||||||||
| NPI: | 1306193347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | BON SECOURS NEUROLOGY CLINIC AT MEMORIAL REGIONAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8580 MAGELLAN PKWY | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232271149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046275462 | ||||||||
| FaxNumber: | 8664490896 | ||||||||
| Practice Location | |||||||||
| Address1: | 8266 ATLEE RD STE 330 | ||||||||
| Address2: | |||||||||
| City: | MECHANICSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231161812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043258720 | ||||||||
| FaxNumber: | 8047647351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | QUIRICONI | ||||||||
| AuthorizedOfficialFirstName: | STEPHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8042818301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | C06115 | 01 | VA | GROUP PTAN | OTHER |